Request for Prior
Authorization of Medication (MEDCO-31) — Physicians use this form to request
prior authorization for medications not typically used for industrial injuries or
occupational diseases. Fax completed MEDCO-31 forms to SXC Health Solutions’s
prior authorization fax number, which is located at the bottom of the form.

Outpatient Medication
Invoice (C-17) — Injured workers should use this form to request payment for
prescribed outpatient medication only. Since pharmacy providers are expected to
submit bills directly to BWC’s pharmacy benefits manager (PBM) electronically,
the use of the C-17 should be rare.Note: Injured workers whose employers are self-insuring should contact their
employers for instructions on billing for outpatient medications. SXC Health
Solutions is not responsible for processing bills in self-insuring claims.

Service Invoice (C-19)
or HCFA 1500 — MCOs determine reimbursement eligibility for the following services
that may be obtained in a pharmacy: durable medical equipment; disposable medical
supplies; and home infusion therapy. Drugs supplied in a physician’s office will not
be reimbursed as outpatient medication. Contact the MCO for specific requirements
for the use of the C-19 and HCFA 1500.